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General NPI Number Information
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NPI Number | 1316963739
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Entity Type | Organization
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Legal Business Name | SOUTHERN BLVD DENTAL CORP, PA
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Dates
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Enumeration Date | 07/15/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2716 SOUTHERN BLVD SE
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City | RIO RANCHO
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State | NM
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Zip | 87124-3741
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Country | US
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Telephone | 505-892-8600
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Fax | 505-892-4215
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Provider Business Mailing Address
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Address Line | 2716 SOUTHERN BLVD SE
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City | RIO RANCHO
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State | NM
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Zip | 87124-3741
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Country | US
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Telephone | 505-892-8600
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Fax | 505-892-4215
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | DR. MARTIN G GOEBBEL
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Credential | DDS
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Telephone | 505-892-8600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DD1523
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DD1498
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License Number State | NM
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